Narrative Reciprocity

By Ri ta C ha ro n

have become curious about reciprocity within clinical

practice. A vast topic that mobilizes considerations of
money, knowledge, kinship, power, culture, and uses
of the body, reciprocity is a strong means by which to
achieve the egality required of just health care. Within
health care, reciprocity might enable not only so-called
shared decision-making and patient autonomy. It might
open the door to mutual acknowledgement of the value
of each participants beliefs and habits. It might appear
as a humble realization that no one understands what
health is and a concurrent welcoming curiosity about one
anothers conception of how the body and speech and
mind work. From the intimate to the international levels
of care, such forms of reciprocity may culminate in the
radical and powerful state of reciprocal recognition.
Only when all participants in a care situation give
and receive can the power and resources of all parties be
seen to matter. The ethos of reciprocity grounds care in
a respectful generosity in which neither the giver nor the
receiver is diminished by the gift. Neither confirmed nor
reinforced, the power hierarchy is seen through and, perhaps, eventually, undermined or even revoked. This is the
way to avoid the curse of slave-master thinking. This is
the way to treat all with regard and freedom. With reciprocity, not only do all participants share in the power
and the giving; they share in being fundamentally transformed in the process of care. Potentiating each participant, reciprocity may lie at the heart of narrative ethics
and perhaps is even the ultimate goal of a narrative approach to ethical deliberation.
In this short essay, I will focus on one aspect of reciprocity in health care: the narrative and potentially recip-

Rita Charon, Narrative Reciprocity, Narrative Ethics: The Role of Stories in

Bioethics, special report, Hastings Center Report 44, no. 1 (2014): S21-S24.
DOI: 10.1002/hast.264

rocal nature of attention in health care. A critical element

in the development of therapeutic alliance, clinical accuracy, and effective practice, attention requires a donation
of the self as a vessel into which can enter that which is
perceived or, from the other side, a penetrating of that
which is perceived so that one sees it from within its own
vessel. It is a muscular form of beholding. Paul Czanne
writes in a letter to his artist colleague Emile Bernard that
[o]ne should penetrate what one has in front of one.1
Attention involves ingress, indwelling, habitation, and,
on the other side, welcome, exposure, hospitality. One
enters the house of the other, however that might be understood, bows to its rules, experiences its ways, surrounds
oneself with its climate. Not just a matter of imagining
or fleetingly adopting the perspective of the other for
the sake of correcting ones own, attention brings alive
the one for the other. It is a form of suscitationone
breathes with the other, animating the other, while the
other is still already alive. When reciprocal, this indwelling and animation happen simultaneously for both.
Not mystical or goofy, the process of attention inheres
in concrete observable situations in which one subject accompanies another with curious, selfless commitment. In
William Maxwells novel So Long, See You Tomorrow, the
ten-year-old unnamed protagonist walks slowly alongside
his young grieving father, the sons arm around the fathers
waist. They have just lost their mother and wife to the flu
pandemic of 1918. The boy has to figure out in which
direction the father will walkfrom the dining room to
the living room, from the living room to the libraryas
if they partake in a slow mournful dance in which the son
lets the father lead and the son lovingly follows. I only
tried to sense, as he was about to turn, which room he
was going to next so we wouldnt bump into each other.
His eyes were focused on things not in those rooms, and
his face was the color of ashes.2 In this scene of pain and

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loss, the danse macabre allows the little boy to ally with or
even, maybe, support his father. I recently had the privilege
to read the manuscript of a midwifes memoir, in which she
describes her practice of knitting a baby cap while sitting
with the birthing woman. Throughout the pulsatile stages
of labors contraction and relaxation, when her presence is
not needed at the bedside, the midwife sits some feet away
from the woman, knitting. She configures the soft pliable
cotton yarn into a garment of warmth and protection for
the child yet to emerge from his or her swimming dark,
configuring as well a purled texture of anticipation, readiness for whatever comes, realism, and hope. That knitted
cap will stand as not the symbol but the evidence of the
midwifes steady, wordless attention throughout the rapids
of birth.3
What is at stake in both these examples is presence, recognition, and donation of the self to the situation of the
other. It is a supple habit with which one perceives, enters,
echoes, and then, as a result, understands the position of
the other.
Seeing a patient in clinical practice does not automatically result in attention. As a general internist in a busy
urban primary care clinic, I have to do many things at
once every time I welcome a patient into the room. I am of
course embroiled in the necessity to act. I am confronted
with the need to analyze, to judge, to decide. I am beset
with states of uncertainty, doubt, and with the feeling of
stupidness, disappointment, admiration, triumph, or love.
Artist and aesthetic theorist Roger Fry, member of Virginia
Woolf s Bloomsbury circle whose biography Woolf wrote,
writes, The more poignant emotions of actual life have,
I think, a kind of numbing effect. . . . [T]he need for responsive action hurries us along and prevents us from ever
realizing fully what the emotion is that we feel. . . . It is only
when an object exists in our lives for no other purpose than
to be seen that we really look at it.4 So in the midst of my
clinic session, Ive taught myself to attendto behold and
to separate the beholding from the acting. I literally sit back
in my chair. I do not turn the computer on at the beginning of the visit. I do not write or type. When I gaze at my
patient, I find that I do what I do while gazing at the Baie
de Marseilles, vue de lEstaque of Czanne, while attending
a jazz piano recital of Fred Hersch, or while standing at
Ground Zero. I receive these works or this place and am
summoned out of my ordinary self by virtue of their integrity, their solemnity, and their beauty.
This happened recently in my practice in the care of a
couple from Albania. Mrs. N. suffered from a dense hearing loss in her left ear. The social worker and I worked long
and hard to get bureaucratic clearance for my patient, who
had neither insurance nor U.S. citizenship, to get all the
diagnostic procedures required for the evaluation by an ear,
nose, and throat specialist. The couple barged into my ofS22

fice some weeks later, both of them weeping, traumatized,

having been told at the ENT clinic that Mrs. N. had a
brain tumor. I knew that the ENT clinic was unlikely to
have an Albanian interpreter and that my patients command of English might not have been adequate for absorbing complex clinical news from strangers. I quickly pulled
up the ENT clinic note and realized they told the couple
that the patient needed to undergo an MRI to find out
if she had a brain tumor. I was able to convey this news
clearly to the couple, and the MRI soon undergone proved
that she did not have a tumor. In the process of this whole
transaction, I became very much affiliated with both husband and wife, taking their side in the contretemps with
the ENT clinic.
As I often do, I wrote a description of this train of events
in the context of an already complex clinical relationship
with Mr. and Mrs. N. I was able, by virtue of writing it, to
understand how powerful for me had been the experience
of caring for this couple over the past several years. I discovered that writing not only helped me to see the couple with
clarity but also enabled me to see myself in the mirror of
their gaze as a dependable and affiliated clinical partner. I
showed the couple what I had written about us, explaining
that they had helped me to understand something about
myself in the process and that the writing functioned as a
self-portrait as well as a clinical portrait of the three of us.
They were surprised and solemnly excited to be engaged in
this process with me and were happy to agree to my suggestion that I submit this short essay for publication in a
medical journal.5
I have incorporated writing into my practice in any
number of forms, from primary-process writing about clinical situations that helps me to expose my thoughts (and
that no one sees but me and, perhaps, a trusted reader) to
extensive narrative descriptions of clinical encounters that
I mail to patients or read aloud to them on subsequent
visits. Often, patients write back in various forms. I typically give patients copies of the notes I write and upload
into the electronic medical record, so that they not only
have an ongoing chronicle of what I think is happening in
their care but also so that they can correct, contest, enrich,
or enlarge that which I have tentatively understood about
our work together.
I am coming to some understanding of what happens
in the course of my clinical writing and why it might support attention and, in turn, why it may permit reciprocal
recognition. No matter who holds the pen, the creative act
of writing brings the perceiver in unique contact with the
perceived. In any act of representation, whether writing or
painting or sculpting or composing, one surrenders oneself
as a maidservant to the observed. One lets oneself be taken
up and used in the service of the representation. The resultant representation is an expression of the consequence
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By writing about situations with patients, I have seen the almost

inevitable dimension of reciprocity. As I gaze at a patient, trying to
recognize his or her situation, I am gazed back at, recognized as
someone who can recognize.
of the beholding. No act of beholding and representation
is replicable, for the outcomes of such acts depend on the
perceived, the perceiver, and the perceiving situationits
temporal, spatial, and meaning-making situation.
Without the representation, there can be no attention.
This is true and not often thought about. Philosopher
Nelson Goodman reminds us that what we look at when
we look at an object is the object as we look upon or conceive it, a version or construal of the object. In representing
an object, we do not copy such a construal or interpretationwe achieve it. 6
While taking a break from writing Roger Frys biography in 1939, Virginia Woolf wrote a memoirish recollection called Sketch of the Past. In it, she describes her felt
experience of writing fiction: [O]ne day walking round
Tavistock Square I made up, as I sometimes make up my
books, To the Lighthouse; in a great, apparently involuntary, rush. One thing burst into another. . . . I wrote the
book very quickly; and when it was written, I ceased to be
obsessed by my mother. . . . I suppose that I did for myself what psycho-analysts do for their patients. I expressed
some very long felt and deeply felt emotion.7
So Czanne, Roger Fry, and Virginia Woolf agree that
the artist is doing something with and to actual life. These
artists are not copying actual life. Instead, they are accepting the value of their own experience of actual life. They
are, in a true manner of speaking, living it. The imaginative life is not a cul-de-sac to the actual life or an elective
pleasure in which some indulge. It is the means by which
human beings know what they are doing in life. It is the
means by which we live.
When events of perception and representation are mutual, with each participant willing to penetrate and accompany the other, reciprocal recognition can be achieved. Mr.
and Mrs. N. helped me to articulate the mutuality of recognition, what Hegel alerted us to in The Phenomenology
of Spirit and what Hannah Arendt, Simone de Beauvoir,
Judith Butler, and Eve Kosofsky Sedgwick, among many,
have written about since.8 Furthermore, it may be that
representation not only helps develop attention and reciprocity but also establishes the capacity for attention and
reciprocity in the first place. Gradually, my practice of internal medicine has invited me and my patients into scenes
of reciprocal recognition. By writing about situations with

patients, I have seen the by now almost inevitable dimension of reciprocityas I gaze at a patient in an effort to
recognize his or her situation, I am gazed back at, being recognized as someone who can recognize. This process
launches me on an ever-building spiral of self-making or,
rather, self-seeing while repeatedly excavating the capacity
within myself for future acts of the recognition of others.
Who knew that taking the MCATs would be the prelude
to this high-stakes, unending, perilous, luxurious process of
sight and growth and being that is at the same time right
and fitting and helpful to others?
Not only the isolated moment of recognition is reciprocal. In a well-going processbe it a clinical relationship,
a teaching and learning relationship, a collaborative partnership, a reader-writer relationship, or a love relationshipan ethos of reciprocity offers a radical alternative to
the framework of unequal power or resources. The ethos of
reciprocity frees us from the dilemma of for whose good?
Whether one examines my clinical relationship with Mr.
and Mrs. N. or the decades-long international health partnership between Indiana University Medical Center and
the Moi Hospital in Kenya, one conceptualizes all participants as givers and receivers, as each having a fundamental stake in and contribution to the engagement and each
having a means of fundamental growth by virtue of the
process.9 A radical reciprocity illuminates and helps one to
navigate the deadly shoals of cultural superiority, beholdedness to deep pockets, imperialism in its many guises, the
use of others, the 1 percent. The subaltern position need
not, perhaps, endure.10 The last time Mr. and Mrs. N. were
in my office, Mrs. N. shyly showed off her new hearing
aid and her new hearing, while proudly regaling me with
the stories of her recent hand-over-heart taking of the U.S.
citizenship oath.
These ambulatory thoughts suggest to me an obligatory
component of representation in our practice of narrative
ethics, not as a means of reporting or recording but as an
aesthetic act of discovery. Although routine clinical medical
practice may not be yet ready to establish the place of creativity and, even, beauty in its realm, the practice of ethics,
informed as it is by introspection, an awareness of values,
and an acute attention to power dynamics, might be open
to suggestions of representational avenues toward a healing reciprocity. Beauvoirs ethics of ambiguity, Sedgwicks

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reparative reading, and Czannes aesthetic penetration

together build toward a powerful, age-old path, through
practice, toward humble sight and welcomed sighting.
The practice of narrative ethics, then, might be contemplated as one that rests on the telling, the telling that rests
on the listening, and the development of the great skills
necessary to tell and to listen. My own narrative medicine
practice builds on my continued schooling in close reading and creative writing so as to receive what others tell, so
as to representand thereby undergothat which I live.
These are the skills fundamental to narrative medicine as
I practice it and as our growing discipline teaches it. By
extension, perhaps, a narrative ethics may well become one
characterized by the telling, the listening, the giving, the
receiving that mark and create the permeable boundaries
between sickness and health, that mark and create the permeable boundaries between self and other.
I cannot predict where these thoughts will lead us. I
have been taught through the repeated experience of being
summoned out of my ordinary self by beholding a patient
in his or her full situation that the care of the sick is a work
of art, a work of art requiring all the creative powers of
sight and discovery at my disposal. Gradually, my narrative
medical practice has shown me that the resources of the self
mobilized by the care of the sick do not stop with scientific
knowledge and technical skill. The care of the sick recruits
ones always new capacity to behold without using up, to
become an instrument for the others use.
The blessing over the Hanukkah candles, those candles
that mysteriously continued to glow long after the lamp
oil ran out, can rest as our final shared thought: These are
not to be used for ordinary purposes. We are only to behold them. No exploitation, no blowing out, no stealing
of light, no lighting for selfthe attention of a narrative
ethical practice develops on behalf of the one who seeks

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care and is purified and mirrored and magnified and made

to last forever.
Acknowledgment

Rita Charons time is supported in part by National

Institutes of Health grant R25 HL108014.
1. P. Czanne, Czannes Letters to Emile Bernard, in The
Courtauld Czannes, ed. S. Buck et al. (London: The Courtauld
Gallery in Association with Paul Holberton Publishing, 2008), 14665, at 153.
2. W. Maxwell, So Long, See You Tomorrow (New York: Random
House/Vintage, 1996), 8.
3. D. Tabas, Belly Buttons and the Torah: A Midwifes
Metaphorical Guide to Finding Holiness and Wholeness Within
(unpublished manuscript, 2013). The author has given me permission to cite from this work.
4. R. Fry, Vision and Design, ed. J. B. Bullen (Mineola, NY: Dover
Publications, 1981), 19, 18.
5. R. Charon, The Reciprocity of RecognitionWhat Medicine
Exposes about Self and Other, New England Journal of Medicine 367
(2012): 1878-81.
6. N. Goodman, Languages of Art: An Approach to a Theory of
Symbols (Indianapolis, IN: Hackett Publishing Company, 1976), 9.
7. V. Woolf, A Sketch of the Past, in Moments of Being, 2nd ed.,
ed. J. Schulkind (San Diego, CA: Harvest/HBJ Book, 1985), 81.
8. G. W. F. Hegel, The Phenomenology of Spirit, trans. A. V. Miller
(Oxford: Oxford University Press, 1977), 111-12; J. Butler, Giving
an Account of Oneself (New York: Fordham University Press, 2005);
H. Arendt, The Human Condition (Chicago: University of Chicago
Press, 1958); E. K. Sedgwick, Touching, Feeling: Affect, Pedagogy,
Performativity (Durham, NC: Duke University Press, 2003); S.
de Beauvoir, Ethics of Ambiguity, trans. B. Frechtman (New York:
Citadel, 1976).
9. R. A. Unmoren, J. E. James, and D. K. Litzelman, Evidence
of Reciprocity in Reports on International Partnerships, Education
Research International no. 603270 (2012): 1-7.
10. G. C. Spivak, Can the Subaltern Speak? in Marxism and the
Interpretation of Culture, ed. C. Nelson and L. Grossberg (Urbana,
IL: University of Illinois Press, 1988), 271-313.

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